Clinical Provider Auditor Lead - Maryland Behavioral Health

Clinical Provider Auditor Lead - Maryland Behavioral Health

Supports Payment Integrity & Behavioral Health

Carelon, a proud member of the Elevance Health family of companies, is a healthcare services organization that takes a whole-health approach to making care more integrated, personalized, and affordable. We put people at the centerconnecting physical, behavioral, social, and pharmacy services, along with clinical expertise, research, operations, and advanced technology to help care work better, together. Among us are specialty-care physicians, nurse practitioners, pharmacists, engineers, data scientists, and other dedicated and caring health professionals. While our roles may differ, our purpose is shared: to make a positive impact on whole health.

A proud member of the Elevance Health family of companies, Carelon Behavioral Health uses our powerful combination of experience, expertise, dedication, and compassion to see what's possible and what's better. Born out of one of the largest healthcare systems organization in the United States, our rich history gives us a unique and valuable perspective on how to solve the most pressing healthcare challenges.

Location: The ideal candidate would need to reside within the state of Maryland and within distance our Hanover, MD Pulse Point.

Field: This field-based role enables associates to primarily operate in the field, traveling to client sites or designated locations as their role requires, with occasional office attendance for meetings or training. This approach ensures flexibility, responsiveness to client needs, and direct, hands-on engagement.

The Clinical Provider Auditor Lead is responsible for leading the professional audit program for a region and manages the work of vendors contracted to perform audits on the company's behalf.

How you will make an impact:

• Leads day-to-day activities of the audit team, providing allocation of resources, establishing priorities, and serving as resource to lower-leveled audit associates.
• Manages vendor relationships with contracted vendors.
• Periodically audits work of vendors and ensures that terms of contract are being satisfied.
• Conducts provider meetings to discuss audit findings and appeals for most complex audits.
• Negotiates settlements.
• Researches claims payment methodologies and fee schedule pricing of claims.
• Adjusts and re-prices claims per audit findings.
• Assists in resolving contractual issues with providers and in reviewing audit process, policy, and procedures.
• Prepares and analyzes various reports to demonstrate recoveries and potential issues with providers.
• Assists manager with reimbursement/audit initiatives as identified.
• Supports enterprise initiatives and develops educational materials for internal staff and providers.

Minimum Qualifications:

• Requires a BA/BS and minimum of 5 years experience in a related field, which could include provider audit, reimbursement; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• Experience related to medical coding, including coding certification and a clinical background, project management and leadership experience strongly preferred.
• Behavioral Health coding and auditing experience preferred.
• Coding certification (CPC, CCS, CPMA) preferred.

For candidates working in person or virtually in the below locations, the salary* range for this specific position is $76,608 - $95,760.

Location: Maryland.

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion, consistent with the law.